Application for Childcare

Application for Childcare

Enrollment Requirements:

 Childcare packet completed in its entirety  Boys & Girls Club Membership Form  Complete Immunization Status Report

 Childcare Registration fee of $50.00 (Includes Annual Membership)  Parent Handbook & Behavior Management Policy

 Documentation of Financial assistance

Child’s Name: _______________________________________________ Grade (current/going into): __________ School: ____________________

Please indicate which program you will be using:

 Before School $ 300 / month

 After School $ 300 / month

 Before AND After School $ 400 / month  Kindercare (before AND after) $ 600 / month  Per Day ( Up to 2 days) $ 200/ month

OF SNOHOMISH COUNTY

MONROE UNIT

SUMMER CAMP REGISTRATION

Contact Information

First Middle Last

Child’s Name___________________________________________________________________ Child’s Birthdate ___________Grade (current/going into) _______Home Phone__________________

Street Address ________________________________City _____________Zip Code_________ 1)Parent/Guardian _______________________________________________Living with Yes No Cell Phone _____________Employment _____________________Work Phone______________ Street Address ________________________________City _____________Zip Code_________ 2)Parent/Guardian _______________________________________________Living with Yes No Cell Phone _____________Employment _____________________Work Phone______________ Street Address ________________________________City _____________Zip Code_________

People to Notify in Case of Emergency

1)Name________________________ Relationship___________ Permission to Pickup Yes No Cell Phone _______________Home Phone ________________Work Phone_______________ Address _______________________City _________________Zip Code__________________ 2)Name________________________ Relationship___________ Permission to Pickup Yes No Cell Phone _______________Home Phone _______________Work Phone________________ Address _______________________City _________________Zip Code__________________ 3)Name________________________ Relationship___________ Permission to Pickup Yes No Cell Phone_______________ Home Phone ________________Work Phone_______________ Address _______________________City __________________Zip Code_________________

Anyone else that has permission to pick up your child

1) Name ________________________Cell Phone ___________Home Phone_______________ 2) Name ________________________Cell Phone ___________Home Phone_______________ 3) Name ________________________Cell Phone ___________Home Phone_______________

DATE CHILD LEFT CARE _________ DATE CHILD ENTERED CARE_________

Child’s Medical Health Information Date of child’s last physical exam_______________ Health Care Provider __________________________Phone Number_______________________ Street Address _______________________________City _______________Zip Code________ Special Health Concerns Y or N Allergies(including medicine reactions) Y or N

Specify Specify

Regular Medications Taken Y or N Other Important Information Y or N

Specify Specify

Child’s Dentist Name __________________________Phone Number_______________________ Date of child’s last dental exam __________________

Insurance Company______________________________Membership#_____________________ Policy Holder Name______________________________Employer________________________ Insurance Company ______________________________Membership#_____________________ Policy Holder Name______________________________Employer________________________

Consent to medical care and treatment of minor child

I give my permission that my child ___________________________may be given first aid/ emergency treatment by a qualified child care provider and/or staff at Boys and Girls Club of Snohomish County, 261 Sky River Parkway, Monroe, WA, 98272.

Disclaimer: If I cannot be contacted, I authorize and consent to medical, survival and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child’s health. I waive my right of informed consent to such treat-ment, but understand that attempts will be made to contact me immediately. I certify under penal-ty or perjury under the laws of the State of Washington that this information is true and correct and that I am the legal parent/guardian of this child. I will be responsible for any and all fees relat-ed to the incident. I waive my right of informrelat-ed consent for treatment.

________________________________ _________ _________________________________ ________ Parent/Guardian Signature Date Parent/Guardian Signature Date

OF SNOHOMISH COUNTY

MONROE UNIT

SUMMER CAMP REGISTRATION

Code of Conduct

Allergies: Let us know and remind us if you

have food, animal or medical allergies.

Code of Conduct: Follow the 4 Rules of

Re-spect. All children will read and sign to help them better understand the policies:

1) Respect yourself wearing appropriate cloth-ing; no violent or vulgar print. No Hoods or face masks.

2) Respect others by being responsible, courte-ous, friendly, sharing, and considerate. 3) Respect the Club, clean up after yourself,

returning all materials to their proper place. Food is to be kept at tables, and only soft sole shoes in the gym.

4) Respect the Staff by following their direc-tion.

Emergency:

1) Evacuation Plans: we hold drills on a

monthly basis in case of fire, earthquake, etc. All youth in the building need to walk safely to the field by the Baseball field and wait for staff to instruct you further. In case of real emergen-cy, even club members cannot leave. We need to count to ensure all have left the building and are accounted for.

2) Emergency Preparedness Plan: Disaster

Response: If there is an earthquake or extreme disaster, please stay on premises so parents know they can come get you at the club.

Field Trip: Forms must be signed by parents in

order to participate, don’t forget to remind them.

Pets: No pets are permitted on the premises.

Illness or lice: Do not come to the club if you

are ill with flu symptoms, diarrhea, vomiting, Pink eye, high fever, contagious infections, or lice. Ask if you have questions on lice control or other. Many people have lice, we will help you get rid of it if you ask.

Items from Home: You should not bring I-

Pods, PSPs, Game Boys, expensive clothing items, or hand held computer devices. If you choose to bring movies or gaming, they must be approved. We are not responsible for lost, stolen, or broken items that you bring. Make

sure you bring coats, towels, swim suits, an other items needed for field trips and out ings. No gum in the building.

Medications: If you have any medications, you

must take them at entry only, and with permission. No medications can be shared.

Sign In: Parents must sign in/out and child

cannot leave without parent/guardian. The staff will sign you in when you arrive after school and you must remain in childcare with the childcare staff until your parent signs you out at the end of the day.

Transportation: If you are riding in the Boys

and Girls Club vehicles for field trips, you must follow seatbelt and all policies.

I have read the Child/Teen Code of Conduct and will follow the rules set forth:

Youth Name_________________________ Youth Signature______________________

MONROE UNIT

Behavior Policy

This contract is a condition for your membership to the Monroe Boys & Girls Club. It is intended to clarify expectations regarding behavior and identify consequences for any incidents of unacceptable conduct. The Monroe Boys & Girls Club is intended to be a positive, safe place for all kids, staff, parents, and visitors. Any unacceptable behavior, or such, is not conducive to this atmosphere.

All members of the Monroe Boys & Girls Club are accountable for their actions, or lack thereof, and are expected to be responsible, exercise good judgment, and make wise choices in order to prevent their conduct from interfering with the rights of others.

In order to prevent any disciplinary actions, you are to: 1. Comply with all Club rules

2. Treat others with respect and common courtesy, including Staff members 3. Exercise self-control and conduct yourself in a safe and responsible manner 4. Respond promptly and courteously to staff directions

Should you engage in unsatisfactory behavior, you may be subject to disciplinary actions, in-cluding the loss of privileged activities. Further disciplinary problems will result in the follow-ing consequences, in order and at the discretion of The Boys & Girls Club staff:

1st Incident Report = Minimum of 1-day suspension from the Club and/or loss of privileged activities.

2nd Incident Report = Minimum of 3-day suspension from the Club.

3rd Incident Report = Extended suspension or expulsion from attending the Monroe Boys & Girls Club.

I, ____________________, understand that it is important that I conduct myself in a responsible and appropriate manner so as not to jeopardize the safety and well being of others at the Monroe Boys & Girls Club. Furthermore, I am aware of the expectations placed on me regarding my be-havior, and acknowledge that I may be subject to disciplinary actions as a consequence of any unacceptable behavior.

Member’s Signature: _____________________ Parent’s Signature: _______________________

Parent Handbook

I, ____________________, have read and agree to all policies and procedures listed in the par-ent handbook of the Monroe Boys & Girls Club. If I have any problems with these procedures I will discuss them with the Childcare Director.

OF SNOHOMISH COUNTY

MONROE UNIT

SUMMER CAMP REGISTRATION

Permissions & Authorizations

Parent Permission Authorization

I hereby give my permission for my child to participate in any/all Monroe Boys and Girls Club Activities, including but not limited to; movies, gaming, sports, artwork, photographs, music, water fun, walks, leaving the premises for field trips, traveling in the Boys and Girls Club’s staffed transportation-public transporta-tion, or private transportatransporta-tion, etc.I will be noti-fied of all field trips prior to and asked to sign up for the trip. I certify (or declare) that I am the parent or legal guardian of the above named child and that I have the authority to authorize such activities and actions.

Any field trip concerns: ___________________ _______________________________________

Parent Initial _______

Medical Treatment

I hereby give my permission that my child may be given first aid/emergency treatment by a qualified child care provider and/or staff at Monroe Boys & Girls Club, 261 Sky River Parkway Monroe WA, 98272.

If I cannot be contacted, I further authorize and consent to medical, survival and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child’s health. I waive my right of informed consent to such treatment.

I also give my permission for my child to be transported by ambulance or aid car to an emer-gency center for treatment. I certify under pen-alty or perjury under the laws of the State of Washington that this information is true and cor-rect. I will be responsible for any and all fees related to the incident. I waive my right of in-formed consent for treatment.

Parent Initial________ I declare that I am the legal parent/guardian of the child noted. To the best of my knowledge my child is in good health and immunized to participate.

__________________________________ __________ Parent/Legal Guardian Signature Date

Immunization record on the following page must be completed.

Sunscreen Permission

During hot weather do you want sunscreen applied to your child? Yes/No

Medications

Will your child be taking any medications while at the Boys & Girls Club? Yes/No If yes please fill out the medication form.

OF SNOHOMISH COUNTY

MONROE UNIT

SUMMER CAMP REGISTRATION

Medication Authorization Form

Child’s Name _____________________________________________Date of Birth__________ Program Name Boys and Girls Club of Snohomish County Today’s Date__________ To administer a prescription medication

1) The medication must be in it’s original container, with a legible label from the pharmacy in-dicating the child’s name, date, name of medicine, dosage, and time, number of days medica-tion is to be given, and expiramedica-tion date of medicamedica-tion, doctor’s/nurse practimedica-tioners name, pharmacy name and telephone number.

2) Samples must be accompanied by a doctor’s written prescription.

3) Medications are to be given only to the child indicated on the label (no siblings can share) 4) A separate authorization is required for each medication and each episode of illness. 5) Label constitutes the physician’s/nurse practitioner’s order.

6) Parent/guardian is to give as many doses as possible at home, we are strictly a back-up for additional doses. (lunchtime)

Medication Name______________________________________________________________ Reason for giving__________________________________________________________ Start date______/_______/_________ End date______/________/____________ Dosage:________________________ Times to be given ________am ________pm Dosage time parent provides ___________am _____________pm

Given by: mouth in eyes on skin (location)___________________

Possible side effects__________________________________________________________ Special handling other than lockbox_____________________________ Refrigeration Yes No We do not provide non-prescription medication from home without written confirmation as to need. If it’s a repetitive medication for migraines, etc, please get a doctors signature and we will keep in lockbox.

Medication_____________________________Purpose________________________________ Doctor’s/Nurse Practitioner Signature______________________________________________ All medication given is documented, and empty bottles you will be notified. It is up to you to keep up the supply.